"Findings from this report provide clear evidence of the importance of promoting gender equity as a means to improve both maternal and child health in Africa and as a means to help countries achieve their MDGs."

From MEASURE Evaluation, which is funded by the United States Agency for International Development (USAID), this report explores the associations between gender measures and several maternal and child health (MCH) outcomes in Africa. The report is premised on the observation that, despite progress, maternal mortality remains high in developing countries, and the United Nations Children's Fund (UNICEF) estimates that about 8.1 million children under the age of five died in the year 2009. Though the treatment and preventative measures to save these women and these children are largely known, access to such services is an obstacle for many around the world and pose a problem for efforts to meet the following Millennium Development Goals (MDGs): #3 (promoting gender equality and empowering women), MDG #4 (reducing child mortality), and MDG #5 (improving maternal health) by 2015.

In short, the report finds that programmes and policies need to facilitate women's empowerment in addition to focusing on educating girls and reducing poverty.

The study looks at the following 8 African countries for which recent Demographic and Health Survey (DHS) data were available: Democratic Republic of the Congo (DRC), Egypt, Ghana, Liberia, Mali, Nigeria, Uganda, and Zambia. The MCH outcomes examined were:

1. low body mass index (BMI), an indicator of overall maternal health;
2. birth in a facility, an indicator of the utilisation of maternal health services and a proxy measure for maternal mortality;
3. having a child who is fully immunised (a child between 12 and 23 months who received 3 doses of oral polio vaccine (OPV), 3 doses of diphtheria, pertussis and tetanus (DPT), and one dose each of Bacille Calmette-Guerin (BCG) and measles vaccine before 12 months of age), an indicator of the utilisation of a preventive child health service; and
4. treatment-seeking for a child with an acute respiratory infection (ARI), an indicator of the utilisation of a curative child health service.

Indicators for each of the outcomes are described. For example, 2 indicators for capturing social norms were used in this analysis. The questions for attitudes regarding inequalities in gender roles were the following: 1) Sometimes a husband is annoyed or angered by things that his wife does. In your opinion is a husband justified in hitting or beating his wife in the following situations: a) If she goes out without telling him? b) If she neglects the children? c) If she argues with him? d) If she refuses to have sex with him? e) If she burns the food? Those who indicated that wife beating is justified for at least one of the items on the list were classified as indicating that wife beating is acceptable. The second question regarding social norms and gender inequality was: 2) Husbands and wives do not always agree on everything. Please tell me if you think that a wife is justified in refusing to have sex with her husband when: a) She knows her husband has a sexually transmitted disease? b) She knows her husband has sex with other women? c) She is tired or not in the mood?

Excerpts from the report follow:
"This report focuses on areas of gender equality known to affect health outcomes for women and children which are available in the DHS data, specifically, women's autonomy within the context of household and financial decision making and social norms regarding attitudes towards wife beating and refusing sex....A series of multivariate logistic regressions were used to study the effect of the gender equity measures on the health outcomes, controlling for the socioeconomic variables.

The strongest associations were between the outcome variables involving access to health facilities (facility delivery, full immunization, and treatment for acute ARI) and the predictor variables education and wealth, both factors associated with much higher likelihood of access. These findings demonstrate the particular importance of the education and wealth variables for the health outcomes examined. In addition to being important in and of themselves, education and wealth can be seen as inputs into the empowerment process. Key findings were that in five of eight countries examined, household and financial decision-making authority were significantly associated with women's general health as measured by low BMI; decision-making authority and attitudes towards gender roles were significantly associated with facility delivery in Nigeria; and attitudes towards gender roles were significantly associated with facility delivery in both Ghana and Uganda. The only gender equity measures significantly associated with a child being fully immunized were the household decision making and wife beating never acceptable variables in Nigeria. Gender equity measures were not significantly associated with treatment for an ARI except in the DRC (where high decision-making authority was protective) and Zambia (where belief that a wife does not have a right to refuse sex was associated with lower likelihood of treatment), though sample sizes for treatment for an ARI were relatively small and are a limitation of the analysis.

That gender equity measures were significant in some countries, even after controlling for education and wealth, suggests that programs and policy should facilitate empowerment in addition to focusing on educating girls and reducing poverty. Since low BMI is often a sign of chronic energy deficiency (CED), women who are consistently able to make decisions and have a financial say may be in a better position to take care of themselves. It could be that gender measures have more influence on overall health than on access to services at certain points in time. Also, this study lacked a variable for accessibility or distance to the nearest facility, which is often a key factor in the ability to seek services. It could be that more empowered women are more able to access services, but if the services are not accessible to begin with then gender would not be a factor.

Recommendations from this report would be for programs and policies to continue focusing on education and poverty reduction and increasing access to services. In addition, programs focused on gender measures can have benefits that go beyond programs focused only on education and poverty reduction. In the countries studied, gender measures were particularly important for a woman's own health. Countless studies have shown the influence of a woman's health on her pregnancy, birth outcomes, and children's health."

MEASURE Evaluation, August 11 2011.